What’s in it for me? See what you can save Here’s an example of what you might pay for a pair of glasses with us vs. what you’d pay without vision coverage. So, let’s say you get an eye exam and choose a frame that costs $163 with single vision lenses that have UV and scratch protection. Now let’s see the difference...
Save
82% with us
With EyeMed (Insight Network)*
Without Insurance
Exam
Exam
$106
Frame
$163
$10 co-pay
Frame $163 -$130 allowance $33 - $ 7 (20% discount off balance) $26 Lens
$20 co-pay $15 +$ 0 $35
Lens
$78 +$23 UV treatment add-on + $25 scratch coating add-on $126
Total
$ 71
Total
$395
Savings
Choice
With a large network of independent and national optical retail providers, you’ll enjoy low out-of-pocket costs in network – plus additional savings.
Forget about limiting frame selections. Choose from the brands you know and love – such as Armani, Coach, Ray-Ban, DKNY and many more.1
Convenience
Wellness
Our member website and iPhone app let you access benefit details and provider locations. Plus, convenient locations with evening and weekend hours make your life easier.
Protecting your vision – and your overall health – begins with an annual, comprehensive eye exam. We’ll help make it as simple as possible.
866-804-0982 • eyemedexchange.com/maxwell-health *Ilustrative example only. Actual savings will vary based on provider, frame and lens selections. 1All brands may not be available at all providers.
Maxwell Health Exchange H6 Vision Benefits Plan
Effective 01/01/16
SUMMARY OF BENEFITS Vision Care Services Insight Network
More for less Great benefit plans, plus additional savings, such as:
40% off
additional complete pairs of prescription eyeglasses1
20% off
non-covered items1
15 % off
retail price of LASIK or PRK Vision Correction at U.S. Laser Network. For LASIK providers call 1.877.5LASER61
In-Network Member Cost
Out-of-Network Reimbursement2
Exam With Dilation as Necessary
$10 co-pay
$30
Retinal Imaging Benefit
Up to $39
N/A
Frames (Any available frame at provider location)
$0 co-pay; $130 allowance, 20% off balance over $130
$65
$20 co-pay $20 co-pay $20 co-pay $20 co-pay $85 Tier 1: $105; Tier 2: $115; Tier 3: $130; Tier 4: $85 co-pay, 80% of charge less $120 allowance
$25 $40 $60 $60 $40 $40
$15 $15 $0 co-pay $40 co-pay $0 co-pay $45 co-pay Tier 1: $57; Tier 2: $68; Tier 3: 80% of charge 20% off retail price
N/A N/A $11 N/A $28 N/A N/A
Standard Plastic Lenses Single Vision Bifocal Trifocal Lenticular Standard Progressive Lens Premium Progressive Lens Lens Options UV Treatment Tint (Solid and Gradient) Standard Plastic Scratch Coating Standard Polycarbonate - Adults Standard Polycarbonate - Kids under 19 Standard Anti-Reflective Coating Premium Anti-Reflective Coating Other Add-Ons and Services
N/A
Contact Lens Fit and Follow-Up (Available once a comprehensive eye exam has been completed.) Standard Contact Lens Fit and Follow-Up:
Up to $55
N/A
Premium Contact Lens Fit and Follow-Up:
10% off retail price
N/A
Contact Lenses (Allowance includes materials only.) Conventional
$0 co-pay; $130 allowance, 15% off balance over $130
$104
Disposable
$0 co-pay; $130 allowance, plus balance over $130
$104
Medically Necessary
$0 co-pay, paid-in-full
$210
Frequency Examination Lenses or Contact Lenses Frames
Once every 12 months Once every 12 months Once every 12 months
Discounts available at participating in-network providers only. Not all in-network providers accept all discounts. 2 Member Reimbursement Out-ofNetwork will be the lesser of the listed amount or the member’s actual cost from the out-of-network provider. Reimbursement may vary based on state law. Benefits are not provided from services or materials arising from: Orthopic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses, medical and/or surgical treatment of the eye, eyes or supporting structures; Any Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; safety eyewear; Services provided as a result of any workers’ compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; Plano (non-prescription) lenses and/or contact lenses; Non-prescription sunglasses; Two pair of glasses in lieu of bifocals; Services or materials provided by any other group benefit plan providing vision care; Certain brand-name Vision Materials in which the manufacturer imposes a no-discount policy; or Services rendered after the date an insured person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the insured Person are within 31 days from the date of such order. Lost or broken lenses, frames, glasses or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would next become available. Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Benefit allowance provides no remaining balance for future use with the same benefits year. Underwritten by Fidelity Security Life Insurance Company of Kansas City, Missouri, Policy number VC-19, form number M-9083. This is a snapshot of your benefits. The Certificate of Insurance is on file with your employeer. Premium progressives and premium antireflective designations are subject to annual review and are subject to change based on market conditions. Fixed pricing is reflective of brands at the listed product level. All providers are not required to carry all brands at all levels. The Insureds' insurance will cease on the earliest of the following date: the date the policy ends; the end of the last period for which any required premium contribution agreed to in writing has been made; the date the Insured is no longer eligible for insurance; or the date the Insureds' employment with the Policyholder ends.
1
PDF-1505-MX-344-H6